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Pediatric Tracheomalacia Workup

  • Author: Emily Concepcion, DO; Chief Editor: Michael R Bye, MD  more...
 
Updated: Oct 25, 2015
 

Laboratory Studies

See the list below:

  • Oxygen saturation should be assessed in tracheomalacia.
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Imaging Studies

Fluoroscopy and radiography

The diagnosis can often be confirmed by performing fluoroscopy of the airway.

During the study, the pediatric radiologist observes the airway collapsing and opening up. This finding may appear on anteroposterior images, on which the tracheal air shadow seems to disappear and reappear with respirations in the affected area of the trachea.

The lesion may be observed most easily on lateral images, on which the anterior and posterior walls of the trachea may be observed apposing dynamically.

Loss of the tracheal air shadow with no respiratory changes suggests static collapse of the airway.

CT scanning

Chest CT scanning may reveal the abnormal shape of the trachea as the apposition of the walls.

"Expiratory frown" shapes are observed in CT scans when the area is scanned during an exhalation or cough.[3]

Chest CT scanning may not reveal the dynamic nature of the lesion and may not depict the lesion at all.

A CT scan, especially one obtained with contrast material, may reveal vascular lesions that mimic tracheomalacia and that may eventually lead to tracheomalacia.

Esophagraphy

Esophagraphy can be performed to evaluate for a vascular anomaly, for a bronchogenic cyst, or for esophageal duplication.

Esophagraphy does not assist the physician in making a definitive diagnosis.

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Other Tests

The definitive method of diagnosis is bronchoscopy. In one series, when a pediatric pulmonologist suspected tracheomalacia, the correct diagnosis was tracheomalacia in 74% of the cases.[1] However, tracheomalacia was not suspected in 52% of patients who were eventually diagnosed with it.

During bronchoscopy, the anterior wall can be observed to collapse against the posterior wall. At the same time, other lesions can be diagnosed or excluded under direct visualization.

The authors prefer flexible bronchoscopy to confirm the diagnosis. With flexible bronchoscopy, the baby is breathing spontaneously with light anesthesia. This method preserves respiratory dynamics better than rigid bronchoscopy. In addition, the rigid bronchoscope may serve as a stent to the airway, masking the diagnosis.

Confirming the diagnosis is important for differential diagnosis. Otherwise, one or more tests may be unnecessarily considered. A sweat test may be performed to reduce the likelihood of cystic fibrosis. Esophagraphy may be performed to eliminate the likelihood of most of the vascular anomalies. These diagnoses are usually eliminated by bronchoscopy. CT scanning to reduce the likelihood of airway foreign body and other lesions that may be compromising the airway. If bronchoscopy is performed, it is an efficient and direct method of looking for foreign bodies.

If tracheomalacia is diagnosed, a sweat test is not necessary unless other manifestations of cystic fibrosis are present. The adage still holds that a sweat test has no contraindication.

If gastroesophageal reflux is a concern, evaluate this condition by using a pH or impedance probe or esophageal biopsy. If bronchoscopy is performed, bronchoalveolar lavage can be done to assess for lipid-laden macrophages.

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Contributor Information and Disclosures
Author

Emily Concepcion, DO Fellow, Department of Pediatric Pulmonology, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Susanna A McColley, MD Professor of Pediatrics, Northwestern University, The Feinberg School of Medicine; Director of Cystic Fibrosis Center, Head, Division of Pulmonary Medicine, Children's Memorial Medical Center of Chicago

Susanna A McColley, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Sleep Disorders Association, American Thoracic Society

Disclosure: Received honoraria from Genentech for speaking and teaching; Received honoraria from Genentech for consulting; Partner received consulting fee from Boston Scientific for consulting; Received honoraria from Gilead for speaking and teaching; Received consulting fee from Caremark for consulting; Received honoraria from Vertex Pharmaceuticals for speaking and teaching.

Acknowledgements

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
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This shows the trachea during inspiration and expiration. Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia.
 
 
 
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